Health Committee - The Government's Alcohol StrategyWritten evidence from the London Health Improvement Board (GAS 63)
This submission provides the Commons Health Committee with information about the London Health Improvement Board’s (LHIB) work on alcohol.
While it does not seek to address specifically all the issues raised with the terms of reference and call for evidence, we do believe that the work of the LHIB around alcohol will be of interest, in particular the evidence base it has identified as well as its ongoing work.
The London Health Improvement Board—An Introduction
1. The LHIB has been initially established in shadow form pending legislation required to put it on a statutory footing. The proposal to establish the LHIB in shadow form was agreed by the Secretary of State in March 2011 following approaches from the Mayor of London and London Councils. Shadow status does not mean that the board is inactive: agreed methods of operating are already underway and the programme has been allocated a budget from April 2012–13 of up to £2 million from the NHS.
2. The LHIB has identified four initial objectives representing major health problems in the capital; cancer, childhood obesity, data transparency and alcohol abuse. These will be addressed by adopting a strategic pan-London view.
3. The Board is chaired by the Mayor of London. Membership is listed in the appendix.
4. While awaiting statutory footing, the membership of the LHIB brings together the Greater London Authority (GLA), London Councils and the NHS. The LHIB and its partners will work closely with colleagues in allied areas such as criminal justice to ensure the most effective responses to the multi-faceted problems associated with alcohol use. All LHIB papers (including references for all data quoted) are available at http://www.lhib.org.uk/
The Impact of Alcohol in London
5. The harmful use of alcohol by a large number of Londoners has a significant adverse impact on a range of health, social, and business outcomes. It is recognised however that many Londoners do not use alcohol, and many who do, use it in ways that pose few risks. Alcohol also provides social and economic benefits for Londoners.
6. The Department of Health estimates that 2.4 million Londoners drink alcohol at harmful and hazardous levels. A further 280,000 are dependent on alcohol. In terms of those for whom alcohol is the most harmful, it is estimated that 400,000 people in London drink 50 units of alcohol or more per week and have an even greater chance of developing serious health problems. (Health guidelines suggest a maximum of three to four units of alcohol a day for men and two to three units a day for women, with one alcohol free day per week, so 50 units represents over twice the recommended levels). Using national data it is estimated that approximately 280,000 Londoners are dependent on alcohol in order to function in their daily life.
7. Trends relating to alcohol harm have been increasing. In the UK consumption was recorded as 9.4 litres in 2004 pure alcohol per capita per year, in 2011 the recorded adult per capita consumption is around 11.7 litres per capita per year. This correlates to additional demands on health and other resources and in some areas, such as alcohol related A&E attendances and crime; the level is so high that a continuing upward trend would be difficult to sustain.
Health Impacts
8. On average, 1,800 people die in London as a direct result of alcohol use per year, with many more suffering ill-health where alcohol is a contributory factor. This rate is increasing.
9. In 2007–08, 1.4% of Londoners were admitted to hospital due to alcohol, with research suggesting this represents under-reporting. In 2009–10, 127,509 individuals or 1.65% of Londoners were admitted into London hospitals as a result of alcohol related harm. Of these admissions one in four were admitted for a wholly attributable (alcohol) condition such as alcoholic liver disease, or severe intoxication. Of major concern is the fact this is a 124% increase from the number of admissions in 2003.
10. Furthermore, rises in death rates from chronic liver disease and cirrhosis have occurred in most age groups in England. In 45–54 year olds, there has been a greater than four-fold increase amongst men since the early 1970s and a three-fold increase in women. In 35–44 year olds, the rise has been even larger: an eight-fold increase in men and approaching a seven-fold increase in women. Analysis of Government data by the British Liver Trust noted a 35% increase in under 35s dying from alcoholic liver disease between 2004 and 2008, and that liver disease was the only major disease in Britain to show a year on year increase since 1970.
11. In Britain, alcohol causes about 6,000 cancers of the mouth, food pipe, voice-box and pharynx—the area at the back of the mouth and top of the throat—3,000 bowel cancers and 2,500 breast cancers. Most of these cases were caused by people drinking more than the recommended daily limits for alcohol, although even drinking small amounts added to the risk of some cancers developing.
12. In London, it is estimated that alcohol related harm accounts for 35% of all A&E attendances, and up to 70% of all attendances at the peak times of midnight to 5am on the weekend. In 2009–10, the London Ambulance service received 60,686 emergency calls because somebody had too much to drink—the equivalent to one call every eight and a half minutes.
13. The impact of alcohol on mental health is significant. It is estimated that in 65% of suicides in the UK, alcohol intoxication plays a part. Alcohol consumption is also strongly linked to self-harm, Scottish research showed it was a factor in 62% of males and 50% of females attending hospital with self-harm injuries.
Social Issues and Criminal Justice
14. Alcohol is strongly linked with a wide range of criminal offences including drink driving, being drunk and disorderly, criminal damage, assaults, domestic violence, and other public disorder offences. According to data produced by the North West Health Observatory, in London the rates of alcohol attributable recorded crimes, violent crimes and sexual violence are all significantly higher than the English average. According to the 2009–10 British Crime Survey, 50% of victims in violent incidents believed that perpetrators were under the influence of alcohol. The same survey also indicates that each year approximately 54,000 Londoner’s are victims of alcohol related domestic violence (where physical injury occurred).
Public Experience, and Attitudes and Willingness to Change
15. More Londoners felt that “people being rowdy or drunk in public places” was a problem in their area than the national average (38% compared to 31% across England and Wales).
16. In March 2011, a survey of 7,500 Londoners conducted by the Greater London Authority and Regional Public Health Group, gathered information about Londoners’ relationship with alcohol. The topline results of the survey were:
72% of Londoners are concerned by alcohol related crime and violence.
51% of Londoners think that if they were given more community power to make decisions over licensing the problems associated with alcohol would improve.
48% of Londoners are concerned about their long term alcohol related health issues.
31% of Londoners feel that there are too many places in their local area where alcohol can be purchased.
52% of Londoners think that employers should have a role in advising employees on alcohol consumption.
Children and Young People
17. In England, between 780,000 and 1.3 million children are affected by parental alcohol problems. A joint Alcohol Concern and The Children’s Society report in 2010 estimated that 2.6 million children live with a parent whose drinking puts them at risk of neglect, and 705,000 live with a dependent drinker. The two charities argued for a national inquiry into the scale of harm and impact on society and for improved resources to protect children.
18. The report highlighted the following:
In a study of four London boroughs, almost two thirds (62%) of all children subject to care proceedings had parents who misused substances.
More than 100 children, including children as young as five, contact ChildLine every week with worries about their parent’s drinking or drug use.
There is evidence of parental substance misuse in 57% of serious case reviews (of serious or fatal child abuse). Since there is currently no routine screening by children and families services for parental alcohol misuse, this is likely to be an underestimate.
Alcohol plays a part in 25–33% of known cases of child abuse.
In a study of young offending cases where the young person was also misusing alcohol, 78% had a history of parental alcohol abuse or domestic abuse within the family.
19. Heavy binge drinking by adolescents and young adults is associated with increased long-term risk for heart disease, high blood pressure, type 2 diabetes, and other metabolic disorders. A UK study found that binge drinking in adolescence was associated with increased risk of health, social, educational and economic adversity continuing into later adult life. The problems included increased risk of alcohol dependence and harmful drinking in adulthood, illicit drug use, poorer educational outcomes, criminal convictions and lower socioeconomic status. In particular:
Young binge drinkers are almost three times more likely to self-report committing an offence than those who drink but do not normally get drunk, and five times more likely than non-drinkers of the same age.
The differences are particularly marked for violent offences. Forty per cent of 13 and 14 year olds reported being “drunk or stoned” when they experienced first sexual intercourse. After binge drinking, one in seven 16–24 year olds have had unprotected sex, one in five have had sex they later regretted and one in ten have been unable to remember if they had sex the night before.
Impact on Inequalities
20. Although alcohol related harm is felt across the socio-economic spectrum in London, it is also linked to significant health and social inequalities. While lower socio-economic groups consume lower levels of alcohol, if they do consume, they are more likely to be exposed to the harmful impacts of alcohol due to having limited protective factors. Alcohol related hospital admissions tend to be higher in areas of deprivation in London. Certain socially and economically deprived groups also suffer disproportionate harm from alcohol. In particular rough sleepers suffer significant harm from alcohol use and are overrepresented in repeat attendances at A&E, repeat admissions and ambulance call outs.
The Economic Impact
21. As a consequence of its health and social impacts, however, alcohol misuse costs approximately £2.46 billion to deal with in London:
£405 million to the NHS.
£825 million as a result of crime and disorder to the police and local government.
£960 million in lost productivity to employers.
£270 million to the wider community.
22. There is an economic benefit from the sale and service of alcohol in London. For example, 1.5% of employees in London work in licensed premises; with many other employees working in associated and ancillary areas. Town centre activity at night provides economic benefits for many boroughs.
23. However, there is evidence (eg London Drink Debate) that many people do not use town centres at night due to the fear of crime and anti-social behaviour. Apart from the impact this has on the general well-being of local communities, it is likely that greater economic benefits for particular areas may come from more people visiting restaurants, theatres and other amenities if alcohol related problems were tackled.
24. Alcohol use also has a major impact on the workplace and therefore creates costs for business. Direct effects include impaired on-the-job performance due to intoxication or withdrawal symptoms, while the indirect consequences include increased absenteeism and impaired performance due to the psychological effects of alcohol abuse. In London, approximately £20 million is spent on supporting individuals who are claiming incapacity benefits because of alcoholism. The FreshStart alcohol clinic in Wandsworth recorded a rate of absenteeism from employment for their patients of 19.2 days a year (approximately double the national average).
25. It is important to keep in mind that the costs outlined above are likely to be higher in the future as a result of the increasing trend in alcohol misuse.
Impact on Local Authorities
26. In 2010–11, almost all London boroughs identified alcohol as an issue that needed to be addressed in their Joint Strategic Needs Assessments. The need to address alcohol related harm was mirrored by Primary Care Trusts in their 2010–11 Commissioning Strategy Plans.
27. Misuse of alcohol puts pressure on social care through the effects of drinking on individuals and families. Costs of child social work associated with parental alcohol misuse were estimated in Leeds in 2008–09 to be between £15.7 million and £38 million. There is no detailed research on the costs to adult social care applicable to London.
28. The cost and burden of alcohol related harm to local authorities cuts across most areas of their responsibility, and with the transfer of public health this will add another responsibility where alcohol harm will require action. The costs are often linked across areas of responsibility; for example an individual requiring housing, adult social care and child safeguarding as a result of their problematic alcohol use.
Global, National and London Comparisons
29. Compared to other English speaking countries Britain has high annual consumption of alcohol, the equivalent of 13.4 litres of pure alcohol per person per annum (Australia 10 litres), New Zealand (9.6 litres), and the US (9.4 litres). The UK also has higher rates of consumption than that of the European average (9.24 litres per person of pure alcohol). Historically, the UK was a relatively moderate consumer compared with other Western European countries. In recent years this has changed and the UK is now one of the heaviest alcohol consuming countries in the world. Liver cirrhosis is often regarded as a proxy for the health damage caused by long-term excessive drinking. In England, liver cirrhosis mortality approximately trebled between 1970 and 1998 and currently rates in the UK are the highest in Western Europe. Compared to the rest of England, London has lower rates of alcohol related health harms, but tends to have a higher level of alcohol related violence, particularly sexual violence.
Effective Actions
30. This section outlines the evidence base for effective action.
31. The World Health Organisation has published a meta-analysis of the evidence relating to effectiveness of policies that reduce alcohol related harm. The study showed that a convincing amount of evidence existed in support of the following policy interventions:
Increasing the cost of alcohol: international evidence shows that increasing the cost of alcohol has a population level impact reducing alcohol related harm.
Restrictions on outlet density: evidence from Australia and New Zealand demonstrates that reducing alcohol outlet density can have an impact on reducing violence and problem drinking.
Restrictions on days and hours of sale: has been shown to reduce population level harm.
Lower legal blood alcohol levels for driving: reductions in alcohol related traffic deaths have been recorded across most western nations as a result of reduced blood alcohol levels and effective enforcement of these.
Identification and Brief Advice programmes (IBA, providing an audit of a person’s drinking and providing a brief intervention if required): UK research has demonstrated that one in eight people who drink hazardously reduce their drinking as a result of undergoing IBA. It is also an effective screening tool for more intensive interventions for dependent and high-risk drinkers.
Treatment for alcohol use disorders: addressing dependence and problematic drinking through specialist treatment increases the likelihood that these drinkers will abstain or reduce their drinking, and therefore reduce the harm they suffer.
32. Media campaigns were not supported as an effective policy intervention due to low evaluation of successful outcomes for these programmes. This evidence has been tested for consistency against a number of studies, efficacy of research and cross-cultural applicability.
LHIB Alcohol Related Activities for 2012
33. Taking account of the evidence base available and the resources it has the London Health Improvement Board is focussing on the enforcement of licensing laws, application of IBA and continued provision of treatment services as the most effective ways of reducing alcohol related harm in the capital. The work is underpinned by a team which brings together expertise and support from regional public health, boroughs, the GLA and other key agencies. The following are the key actions being undertaken in 2012:
Developing a London vision: working with stakeholders to ensure support and aligning actions with key partners
Responsible supply: supporting London Councils and licensing to develop a compendium of licensing best practice and support best practice implementation. Work to develop a best practice scheme for off–licence sales. Develop a cost benefit analysis tool on the night time economy. Engage with businesses to improve responsibility training. Look to expand and build upon existing schemes (Best Bar None, Purple Flag).
Early interventions: maintain and develop the delivery of Identification and Brief Advice programmes. Support the development of early interventions in the criminal justice sector and work with the Mayor’s Office for Policing and Crime on delivering sobriety schemes.
May 2012
APPENDIX
MEMBERSHIP OF THE LONDON HEALTH IMPROVEMENT BOARD
The Mayor of London, Boris Johnson—Chair
Cllr Teresa O’Neill, Leader—London Borough of Bexley
Cllr Julian Bell, Leader—London Borough of Ealing
Cllr Derek Osbourne, Leader—Royal Borough of Kingston Upon Thames
Cllr Liam Smith, Leader—London Borough of Barking and Dagenham
Dame Ruth Carnall, Chief Executive—NHS London
Alwen Williams, Inner North East London Cluster Chief Executive
Dr Howard Freeman, GP and chair of London GP Council
Prof David Fish, Managing Director of UCL Partners
Dr Simon Tanner, Regional Director for Public Health in London and statutory health advisor to the Mayor